Physiotherapist's guide
Disc herniation: why it hurts and what to do before considering surgery
If your MRI says “herniation” and you feel your life has stopped, this guide is for you. What it is, what that image really means and where to start.
What a disc herniation is, in plain words
Between each vertebra there is a disc: a cushion with a gel-like centre and a firmer outer ring. With age, or repeated loads, that ring tears and the centre shifts outwards. That is a herniation. Depending on which way it moves, it may stay in the back or touch the nerve that runs down your leg.
The first thing you need to know is that a herniation is an imaging finding, not a diagnosis of pain. In the most cited review on this (Brinjikji et al., American Journal of Neuroradiology, 2015) researchers pooled 33 studies and more than 3,100 people with no back pain at all: half of those aged 40 had a disc bulge and did not know it. The image tells you how your disc looks. It does not tell you how much it hurts or what you can do.
So why does it hurt?
When the disc touches a nerve root, the nerve gets irritated and the pain travels down the buttock and the leg with tingling, burning or cramps. That is sciatica, and it hurts for real.
But when pain has lasted for months there is something else going on: the nervous system learns to protect the area. The threshold drops, and movements that used to be normal now set off pain. It is like a house alarm left switched on. That is what I mean when I say the pain is not only in your spine.
That is why two people with the same MRI live opposite lives: one works without trouble and the other cannot bend down. The difference is not the size of the herniation: it is how their nervous system interprets what it receives.
What actually helps
- Move, in measured doses. Prolonged rest weakens the area and raises pain sensitivity. Recovery comes from progressive movement, not stillness.
- Understand your pain. Knowing why it hurts lowers fear, and fear is part of the problem: when you dread a movement, your body protects it by tensing more.
- Recover your posture pattern and your breathing (RPG). Most lumbar hernias live alongside an excessive lumbar curve and a diaphragm that does not follow.
- Return to loading in stages. Sitting, walking, bending and lifting come back with an agreed progression, not by trial and error.
- Sleep and lower your stress. Short sleep and sustained stress keep the alarm switched on, however well you do your exercises.
What is worth stopping
- Waiting months for it to pass on its own without changing anything.
- Weeks of bed rest: we now know it goes against recovery.
- Stopping all movement for fear of “breaking something else”: a disc does not rupture because you move with judgement.
- Copying exercises from the internet without knowing whether they suit your case; some movements are best avoided at the start.
- Deciding on surgery from the image alone, with no full clinical examination. Surgery has its place, and your treating doctor defines it with your history and your progress in hand, not with a photograph.
Warning signs
When not to wait and to seek urgent care
Some signs are not handled over WhatsApp or with exercises. If any of these appear, go to an emergency department today:
- Progressive weakness in the leg or foot (your foot trips as you walk).
- Numbness in the area that touches a bicycle saddle: between the legs and the genitals.
- Difficulty urinating, or losing control of your bladder.
- Pain that started after a hard blow or a fall.
- Fever, unexplained weight loss or a history of cancer.
- Pain that wakes you every night and does not ease in any position.
Questions I get about this
Does a herniated disc heal on its own?
Many people improve without surgery within weeks or months, and in some cases the disc is partially reabsorbed. What decides your recovery is not only the disc: it also depends on how much you move, how well you rest and how much you fear movement.
Can I exercise with a herniated disc?
Almost always yes, in measured doses. It is not about stopping exercise, but about adjusting what, how much and in what order. At the start we avoid the loads that compress the area and build from there.
Does the MRI tell me how much it will hurt?
No. The image shows the structure of the disc, not the intensity of your pain. There are large herniations that hurt little and small ones that hurt a lot, because pain also depends on the state of your nervous system.
Does this replace my treating doctor?
No. My work is the functional side: movement, pain management and education so that you understand what is happening. Diagnosis, imaging and the decision about surgery belong to your treating doctor.
Do you see patients outside Medellín?
Yes. Assessment and sessions are virtual: I work from Medellín for any country, in Spanish or English.
Educational content
Written and reviewed by Juliana Lopera Isaza . Physiotherapist specialised in the spine, RPG and pain neuroscience.
If this has gone on for months, let us start by understanding your case
In the assessment I review your history, your image and how you move, and I tell you honestly whether I can help.